20131013 03 黃曉峰_安寧緩和照護團隊之決策與溝通 [相容模式]

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2. () ? () () ? () Hypothyroidism TSH 46 () 2 3. (30) ? ICU ICU, , , , DNR , , ? ! ? 3 4. ? 16 , Leukemia, 8 !( ) 76COPD15 ICU COPD . ... 4 5. () (Dr.A) COPD () () () () (Dr.B) () ( ...) Dr.BDr. A ( ) 5 6. CLASSRobert Buckman, MB,PhD,FRCP,FRCP( C ) Medical Oncologist and Associate Professor of Medicine, Toronto-Bayview Regional Cancer Centre, University of Toronto, Canada London:Pan books, 1994 Context Listening Skills- Acknowledgement of Emotions Strategy Summary Buckman R. How to break bad news A guide for healthcare professionals. London:Pan books, 1994; --Practical Plans for Difficult Conversations in Medicine. JHU press, 2010Communication Hourglass Dr. Robert Buckman 2010 Many doctors are potentially caring, just that they dont know how to do it.Patients: Symptoms, prognosis Symptoms prognosis, Concerns side effects, family, finance, more Clinicians: Optimal management management, risk-benefit, sequelae, more Clinician-Patient meeting MedicalSupportive (person-centered): Symptom management, social support, psychotherapy/ psychiatry, more Management Plan(condition-centered): Optimal disease management, riskbenefit, side effects, more 6 7. SPIKES Step 1 Setting 1. Step 2. Perception Step 3. Invitation Step 4. Knowledge Step 5 Empathy 5. Step 6. Strategy W60 Breast cancer with lung metastasis C/T R/T CXR CHEST CT Lung Metastasis 12 O2 NASAL MASK 50 % CRITICAL W W 7 8. W W DNR Curative treatmentpalliation Death /; EAPC atlas of palliative care in Europe 2007 49W DNR DNR 8 9. / W / DNR vs CPR vs. 9 10. Hope for cure Hope for prolonging life Hope f a better H for b tt quality of Life Hope for a good quality of Death- 12 12 W 10 11. Direct or Factual Response (V) Escalationary or Judgmental Response ( ) (X) Reassuring Response (X) E Empathic Response hi R (V) Open Questions (V) -Robert Buckman, Practical Plans for Difficult Conservations in Medicine, John Hopkins U. Press, 2010 11 12. (SPIKES) Setting OK OK Perception Invitation ...(SPIKES) Knowledge Empathy ( ) Knowledge Open Q Empathy (SPIKES) Knowledge Strategy/ Summary ...12 13. : . : Buckmann R. How to break bad news A guide for healthcare professionals. London:Pan books, 1994 -- Acknowledge g the emotion XXX XXX XXX / xxx , 2004; Robert Buckman, 1994 ( ) () ( )+ ( ) (... ... ...) () ()13 14. (factual response) n unspoken question? (Open Question) (E (Empathic thi response) -Robert Buckman 53// PQ : :/ Q P :/ : ()Opioids (or) (or) ? / =14 15. -metastatic adenoca of bil. neck LN-metastatic adenoca of bil. neck LN :(2)(2) A A : L :L :T : 65y/o male, Metastatic adenoca, bil neck, primary unkown. unkown Diagnosed 2 months ago, Refractory to C/T. Dyspnea, death rattle, weakness, not in pain. : : : -metastatic adenoca of bil. neck LN : () , () () ()15 16. -metastatic adenoca of bil. neck LN : ! ! ( ) ! () -metastatic adenoca of bil. neck LN : (ignore) () () Faulkner A. in ABC of Palliative Care. BMJ Books 1998. P.47-916 17. 55 55 17 18. DNR 18 19. 19 20. SPIKES SPIKES clinical encounter with the patient/family1. 2. 3. 4. 4 to support the patient and the family through the crisis of his/her illness -R.Buckman, W.F.BailePrescribing the Doctor as Part of the Treatment Robert Buckman, Practical Plans for Difficult Conversations in Medicine. John Hopkins U. press, 2010in:. Gynecologic Oncology 5th ed, 2010, p.82020 21. TAKE HOME MESSAGES (spiritual distress) Physical dimension () 21